Transcript/School Information Request

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For Rush-Henrietta graduates in need of a transcript, please complete the following information. Please allow five business days to process your request. Current students should speak with Karen Tambasco in the high school counseling office.

1.	Name

2.	Name Used in High School (if different)

3.	Year of Graduation

4.	(Or Year You Left the District)

5.	Date of Birth

6.	What information are you requesting?
	What information are you requesting? Transcript Immunizations Record Special Education Reports Entire File

7.	How would you like to receive the information?
	How would you like to receive the information? Mail it to my college or job Mail it to my house Fax it Will pick it up

8.	Please provide the name of the university or employer and the address or fax number to which Rush-Henrietta should send the information.

9.	My address is:

10.	My phone number and email address are:

11.	Were you involved in any special programs, i.e. SCORE, special education, etc.?
	Were you involved in any special programs, i.e. SCORE, special education, etc.? Yes No

12.	If you need special education reports, please select what you need:
	If you need special education reports, please select what you need: IEP Medical Reports Psychoeducational Report Social History